Opioids first-line for pain relief in palliative care

8041706-article-pallativeOpioids should be prescribed to help relieve pain in patients receiving palliative care for chronic or incurable illnesses, says NICE.

For many people with cancer, heart failure or other chronic or neurodegenerative conditions, strong opioids like morphine are the only adequate source of pain relief.

However, evidence suggests that pain caused by advanced disease remains under-treated despite a range of opioids being recommended for use on the NHS.

Some healthcare professionals have reservations about prescribing strong opioids, and many patients worry about the long-term use of opioids, their side-effects and the possibility of becoming addicted.

This latest guidance aims to ensure safe and consistent prescribing of opioids as a first-line treatment option to relieve pain for patients receiving palliative care.

NICE recommends that when offering patients pain treatment with strong opioids, healthcare professionals should discuss any possible concerns such as: addiction, tolerance, side effects, fears that treatment implies the final stages of life.

Patients should be offered access to frequent review of pain control and side effects and information on who to contact out of hours, particularly during initiation of treatment.

When starting treatment with strong opioids, healthcare professionals should offer patients with advanced and progressive disease regular oral sustained-release or immediate-release preparations, with rescue doses of oral immediate-release preparations for breakthrough pain.

Oral sustained-release morphine is recommended as the first-line maintenance therapy to patients with advanced and progressive disease who require strong opioids. If pain remains uncontrolled despite optimising first-line therapy, review analgesic strategy and consider seeking specialist advice.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: “Many people with chronic or advanced conditions will experience a high level of pain which can only be treated by opioids such as morphine as weaker forms of pain relief will no longer be effective.

“However, we understand that patients can be anxious about using these medicines for a number of reasons. Likewise, healthcare professionals may not always be sure about when to prescribe certain types of opioids.

“The new guideline aims to address all those fears and provide clear advice to the NHS to ensure a consistent approach to treatment and ultimately help to drive up standards of care.”

Dr Damien Longson, Chair of the Guideline Development Group (GDG) for this guideline, said: “Because opioids are powerful medicines people worry they can become addicted, particularly if opioids are prescribed over an extended period of time.

“This guideline puts a strong emphasis on good communication between healthcare professionals and patients, which is key to ensuring any worries or uncertainties are addressed with timely and accurate information. This will help the patient to feel content in following what has been prescribed and therefore potentially improving their pain control and reducing any associated side effects.”

Dr Lindsay Smith, a Somerset GP and member of the GDG, said: “Primary care professionals have an increasingly important role to play in the prescribing of medicines for people who have chronic or advanced conditions and require strong pain relief.

“Many people with long-term health conditions continue to live at home and will therefore depend on the knowledge and advice of their GP.

“This guideline will ensure opioids are prescribed appropriately and safely across primary and secondary care. I hope this consistency will be welcomed not just by GPs but also by other doctors involved in initiating strong opioids as a pain-reliever for patients with long-term or advanced illnesses.”

Natalie Laine, whose husband Mark passed away in 2009 from motor neurone disease, also helped to develop the guideline. She said:Having had to watch Mark deal with the impact, complications and fears of opioid use, I was keen to try and help produce a guideline that would give the best possible care to other patients with incurable illnesses, whatever they may be suffering from.

“These people are sadly facing the scariest time of their lives and correct opioid use can make all the difference in minimising pain and helping them to feel comfortable.”

Listen to a podcast with Mike Bennett, a Professor in Palliative Medicine at Leeds Institute of Health Sciences who was also involved in developing the guidelines, as he discusses the evidence behind the recommendations.

23 May 2012

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.